Postoperative Corneal Complications

Severe corneal complications after refractive surgery are rare but are sometimes difficult to manage when they occur, notes José Luis Güell MD, PhD.

“Although elective refractive surgery has a very high safety index and patient satisfaction rate—and serious complications are rare—the numbers are significant because the number of refractive procedures is extremely high,” he said.

Significant residual opacities with or without surface irregularities account for most severe complications after corneal refractive surgery. The clinical assessment should begin with an evaluation of best-corrected vision with rigid permeable contact lenses and a meticulous examination of the cornea with slit lamp, topography, and anterior segment OCT.

If the opacity is minor or not central, cases with various irregularities are often managed with rigid corneal or scleral lenses. Examples of cases Professor Güell has successfully treated in this manner include an eye with high irregular astigmatism as a long-term complication of radial keratotomy and a patient with significant visual loss due to corneal thinning and irregularity after a complicated PRK.

Surgically repairing a LASIK flap may be necessary in some cases. In eyes featuring large folds, he recommended removing the epithelium from the flap before elevating it and placing it back down on the stromal bed. No flap stretching is necessary during this manoeuvre, provided the epithelium is removed. Epithelial ingrowth treatment is more complex, sometimes requiring a peribulbar block to allow the surgeon to meticulously remove the epithelium from both sides of the flap. Sutures should be used to secure the flap and prevent regrowth.

Superficial anterior lamellar keratoplasty should only be considered when opacity is the problem and there is no significant irregular astigmatism because the anterior lamellar cut will leave the irregularity intact. Topography-guided PRK, with or without cross-linking, can also be an option in such eyes, provided there is no significant irregularity, the cornea is sufficiently stable, and the ablation depth does not exceed 100 microns.

However, in most cases where there is significant opacity, deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PK) will be necessary to restore vision. If the endothelium is healthy, DALK is preferable to PK. Among his successful DALK cases, Prof Güell shared a contact lens-intolerant patient with significant corneal irregularity and stromal lysis after a complicated PRK and an eye with post-LASIK ectasia in which intracorneal ring segments had failed to resolve.

He noted that PK may be indicated in eyes where the irregularity is more extreme, as in the case of the contact lens-intolerant patient who, in addition to developing severe irregular astigmatism after PRK, also had a cataract. Prof Güell removed the cataract and performed PK in one procedure, delaying intraocular lens implantation for a few months to allow more precise biometric calculations. He observed this approach is also useful for cataract patients undergoing DALK to correct refractive surgery complications.

Prof Güell concluded his remarks by presenting several cases where endothelial keratoplasty was indicated due to intraocular refractive surgery damage to the endothelium.

Prof Güell made his presentation at the 2025 ESCRS Annual Congress in Copenhagen.

José Luis Güell MD, PhD is Director of the Cornea and Refractive Surgery Unit, Instituto Microcirugia Ocular of Barcelona, Spain; Professor of the IMO Master Programme UAB; Lead Professor and Coordinator, Anterior Segment Diseases European School for Advanced Studies in Ophthalmology (ESASO), Lugano, Switzerland. jose.guell@imo.es